ETHICAL AND LEGAL PRINCIPLES
Katherine R. Casale
EXPECTED LEARNING OUTCOMES
After completing this chapter, the student will be able to:
1. Identify ethical theories that may be used when providing care to psychiatric-mental health patients
2. Analyze the steps of the ethical decision-making process, applying them to nursing processes
3. Describe the rights and responsibilities of psychiatric-mental health patients across the continuum of care
4. Compare the similarities and differences between voluntary and involuntary admission for mental health care
5. Describe the concepts of competency and self-determination as they apply to the psychiatric-mental health patient
6. Explain the methods for ensuring patient safety when implementing restraint and seclusion
7. Discuss the responsibilities of the psychiatric-mental health nurses (PMHNs) in providing ethical and legal nursing care
Psychiatric-mental health nurses (PMHNs) make critical decisions about patient care every day. To make the best decisions, they must reflect on principles of good and bad as well as consider which choices benefit the individual as well as the group. Ethical and legal decision-making situations are seldom black or white, and this is especially true in psychiatric-mental health nursing. Therefore, PMHNs need a firm understanding of ethical theories and legal tenets that form the foundation from which to make ethical and legal decisions to protect their patients and themselves.
This chapter discusses the major ethical theories used as a foundation for ethical decision making and presents an example of the process based on the nursing process. The chapter describes the legal issues involved in psychiatric-mental health nursing care and treatment, and addresses the nursing responsibilities necessary to ensure the ethical and legal provision of care.
ETHICS is a collection of philosophical principles that examine the rightness and wrongness of decisions and conduct as human beings. Ethicists, including nursing scholars and clinical ethics consultants, use various approaches to address practical moral dilemmas (Pagan, 2014). Personal moral convictions of PMHNs serve as a foundation to reflect on ethical quandaries that arise in their daily work (Cleary & Horsfall, 2013, Park, Jeon, Hong, & Cho, 2014). Nurses who are engaged in providing care to patients with mental illnesses face unique challenges that can test their moral and ethical reasoning. Thus, an understanding of ethical theories and principles is important in determining the proper decision.
The scope of responsibility as well as the rights and standards of practice for professional nurses is clearly delineated in the American Nurses Association (ANA) Code of Ethics for Nurses With Interpretive Statements (2001). This code is a written statement of the expected behaviors and practices of every nurse every day. The practice of nursing requires ethical conduct and moral decision making during the care of patients; the Code of Ethics is updated regularly to guide nurses in their daily duties, whether providing direct or indirect care to those patients.
The ANA Code of Ethics and the International Council of Nurses (ICN) Code of Ethics for Nurses both specifically address nursing behavior in the workplace. Behavior among coworkers and colleagues has recently been spotlighted as a result of increasing incidences of incivility and bullying among nursing colleagues. PMHNs must recognize the elements that comprise uncivil professional behavior and correlate these behaviors with the related ethical and legal issues. Nurses who witness or participate in incivility violate ethical principles of nonmaleficence, beneficence, and justice and breach the character virtues of compassion and integrity (Matt, 2012).
The mental health of care providers must also be ensured, as they provide routine care and also because they respond to natural and man-made disasters. In addition to risking physical harm and injuries, first responders to disasters are at increased risk for psychological harm at the time of the event and also for months and years into the future. Rutkow, Gable, and Links (2011) reference studies that uncovered increased incidences of posttraumatic stress disorder (PTSD) as well as depression, anxiety, and stress-related illnesses in first responders including mental health workers. Additionally, responders with existing mental health conditions may suffer exacerbations as a result of repeated or long-term exposure to public health emergencies and disasters (Call, Pfefferbaum, Jenuwine, & Flynn, 2012).
In the face of ever-changing technology, nurses encounter increased responsibilities and increased stress. First and foremost, the nurse has a primary responsibility to protect the rights, health, and safety of the patient. However, exactly how does the nurse act ethically to protect the patient? Evidence-Based Practice 28-1 summarizes two important studies related to doing the right thing and the ethical nursing practice.
Ethics involves the principles that address right and wrong.
Ethical Theories and Principles
Several ethical theories and principles mold the professional practice of psychiatric-mental health nursing and provide a firm foundation to guide professional decision making.
UTILITARIANISM professes that decisions should be based on producing the best outcome or the greatest happiness for the greatest number of people. Proponents of utilitarianism believe that the end justifies the means, whereas opponents might argue that the interests of the minority and of individuals who lack assets and access to health care should not be ignored (Thompson, 2014).
The ethical principle of KANTIANISM is in contrast to utilitarianism. It focuses primarily on performing one’s duty rather than the “rightness” or “wrongness” of the outcome. This theory explores the concepts of AUTONOMY (capacity to make decisions and act on them), BENEFICENCE (doing what is best), NONMALEFICENCE (doing no harm), JUSTICE (fair and equal treatment), VERACITY (honesty and truthfulness), and FIDELITY (acting as promised).
EVIDENCE-BASED PRACTICE 28-1:
Catlett, S., & Lovan, C. (2011). Being a good nurse and doing the right thing: A replication study. Nursing Ethics, 18(1), 54–63.
Smith, K. V., & Godfrey, N. S. (2002). Being a good nurse and doing the right thing: A qualitative study. Nursing Ethics, 9(1), 301–312.
This qualitative research effort that was undertaken in 2002 and replicated almost a decade later identifies four areas in which nurses are characterized as ethical and good practitioners. Philosophers define ethical behavior as being morally sound with virtuous actions. In nursing, this is translated into caring practice. Both Smith and Godfrey’s original research and Catlett and Lovan’s reexamination of the topic reinforced the concept of intentional ethical caring as an essential quality of the good nurse. Participants described good nurses who consistently do the right thing in four general areas: “personal traits and attributes, technical skills and management of care, work environment and co-workers, and caring and caring behaviors” (Catlett & Lovan, 2011, p. 58). Organizations can use these findings to hire nurses who demonstrate these skills and can provide continuing education to reinforce and strengthen these essential attributes. Working in an ethical environment improves job satisfaction, strengthens retention, and minimizes job turnover.
APPLICATION TO PRACTICE
Findings from both studies demonstrate the complexity of training needed to develop ethical, caring nurses. The nurse’s ability to perform technical tasks efficiently and safely is only one trait of the good nurse. This knowledge has a significant impact on professional nursing education, as students must focus on developing character traits in addition to clinical competence. Characteristics such as trustworthiness, caring, honesty, and empathy can be learned and reinforced in the classroom. Nursing students can hone and perfect the interpersonal skills that make nurses among the most trusted professionals in the workforce through the use of case studies, simulation, and clinical practice. Students who struggle with making ethical choices can learn to do so by observing peer mentors and faculty.
QUESTIONS TO PONDER
1. How has the health care environment changed since the original study was conducted?
2. Consider the following: You are one of two registered nurses working nightshift on a mental health unit. A patient on the unit is prescribed diazepam 5 mg every 8 hours as needed for anxiety. You observe that the patient is calm and relaxed in bed at 11:00 p.m. At 11:05 p.m., you note that the other registered nurse pulls a dose of diazepam for the patient, but does not bring it to the patient’s room. How would you handle this situation?
Beneficence and nonmaleficence focus on patient advocacy; that is, doing what is best for the patient and not doing anything that will harm him or her. These two principles go hand in hand. Beneficence forms the foundation for all care decisions. For example, beneficence is demonstrated by administering antidepressant medications to a patient experiencing depression, providing emotional support to patients experiencing anxiety, and identifying signs that a patient is being abused. Nonmaleficence expands the principle of beneficence and involves actions that are proactive. For example, in the case of abuse, the nurse reports this abuse to reduce the risk for recurrence. Nonmaleficence is also at the core of nursing research; research informed consent asserts a promise to not intentionally harm participants (Murray, 2014; Tsitsis, 2014).
Doing the “right” thing implies that every individual has the ability to make an informed choice (autonomy). However, this concept of autonomy is flawed when one considers the decision-making abilities of certain subpopulations, such as infants and patients who are considered legally incompetent. PMHNs must recognize that individuals with serious, uncontrolled mental illness may not be capable of making an independent choice. In that instance, it is the responsibility of the mental health care team to make certain that the rights of each patient are protected by an appointed representative. At times, to preserve the safety of the patient and those around him or her, a patient may lose the right of SELF-DETERMINATION (freedom to make decisions without consulting others). In addition, PMHNs constantly use critical thinking to ensure a balance between autonomy and beneficence. At times, the difficulty lies in deciding which ethical principle should have the highest priority.
Nursing theorist Hildegard Peplau proposed that a primary role of the PMHN is that of patient advocate and supporter. She emphasized that nurses should provide education about patients’ rights, choices, and access to services (Merritt & Procter, 2010).
The concept of justice refers to distributing resources equally to all patients and combating discrimination of any type. The just PMHN treats all patients fairly and equally. Promoting SOCIAL JUSTICE may prove difficult in societies where there is distinction between people who have resources and easy access to all levels of health care and those who lack resources and access. Many of our patients have shortened life expectancies and decreased quality of life resulting from health care inequity (Pearson, 2012; Thompson, 2014). Nurses fight these injustices with caring commitment to all patients; recent nursing literature emphasizes the importance of nursing practices that promote social health equity and justice. Passage of the Affordable Care Act in the United States has provided reasonably priced health care coverage to previously uninsured individuals to promote health equity and social justice (Shaffer, 2013).
Veracity and fidelity, being honest and faithful, are two similar ethical principles that may be difficult to maintain. Lachman (2008) noted: “Because of cost and access constraints in today’s health care environment, the virtues of honesty and integrity are constantly under assault. Integrity can be preserved only if nurses’ actions are consistent with the values and ethics of the profession.” Box 28-1 lists the ethical principles and theories and how the PMHN applies them.
Model for Ethical Decision Making
Throughout the educational experience, nursing students are encouraged to engage in the nursing process for clinical decision making. Peplau, known for her work with the interpersonal process (see Chapter 2), identified four phases of the nurse–patient relationship that have been correlated to the nursing process. Both can be integrated and adapted for use as a guide for ethical decision making in psychiatric-mental health nursing. The following example demonstrates the steps of the decision-making process for a PMHN who encounters an ethical dilemma. It also incorporates several ethical principles that the nurse needs to consider during the process. Ethical principles evolved from theories of human morality. Nurses may face instances in which immediate benefit and long-term benefit may conflict or when limited resources are available and decisions must be made to weigh which decision will promote the greatest positive impact (Ivanov & Oden, 2013). PMHNs have a strong voice to influence beneficent care of patients while maintaining safety and promoting quality (Kangasniemi,Vaismoradi, Jasper, & Turunen).
Ethical theories and principles provide the foundation from which the PMHN integrates the nursing process to make an ethical decision when faced with an ethical dilemma.
George is a 22-year-old recent college graduate with a degree in international business. He is in excellent health except for a recent depressed mood. George has $60,000 in unpaid student loans, which are coming due. He has been unable to find a job during the last 4 months since graduation. He has depleted his meager savings and is sleeping on a friend’s couch and eating meals at a homeless shelter. George knows he will need to find new living arrangements soon. He has been diagnosed with situational depression at the local community health clinic and has been taking fluoxetine (Prozac) for 2 weeks. He is treated by Jamal, a psychiatric advanced practice nurse.
BOX 28-1: APPLYING ETHICAL THEORIES AND PRINCIPLES TO PSYCHIATRIC-MENTAL HEALTH NURSING
The nurse adheres to the ANA Code of Ethics.
The nurse collaborates with other health professionals and the public in promoting community, national, and international efforts to meet health needs.
The nurse participates in the advancement of the profession through contributions to practice, education, administration, and knowledge development.
The nurse participates in establishing, maintaining, and improving health care environments and conditions of employment conducive to the provision of quality health care and consistent with the values of the profession through individual and collective action.
The nurse promotes, advocates for, and strives to protect the health, safety, and rights of the patient.
Beneficence and nonmaleficence
The profession of nursing, as represented by associations and their members, is responsible for articulating nursing values, for maintaining the integrity of the profession and its practice, and for shaping social policy.
The nurse, in all professional relationships, practices with compassion and respect for the inherent dignity, worth, and uniqueness of every individual, unrestricted by considerations of social or economic status, personal attributes, or the nature of health problems.
The nurse owes the same duties to self as to others, including the responsibility to preserve integrity and safety, to maintain competence, and to continue personal and professional growth.
The nurse’s primary commitment is to the patient, whether an individual, family, group, or community.
From the American Nurses Association (2001).
On the Internet, George discovers a private clinic in Mexico that is searching for voluntary organ donors. The advertisement states that the clinic will pay $75,000 for a kidney donated from a person with type AB blood. George has type AB blood and becomes excited about the possibility of selling one of his kidneys. He can pay off his loan and be able to afford to rent and furnish an apartment of his own. He shows the advertisement to Jamal and asks his advice.
Identification Phase/Nursing Diagnoses and Planning
Based on the assessment, some possible nursing diagnoses might be:
Ineffective community coping related to deficits in financial resources
Fear related to financial and potential health stressors
Powerlessness related to community and financial stressors
Risk for compromised human dignity related to potential change in body integrity
Risk for complicated grieving related to lack of job and potential loss of body part
Risk for infection related to surgery at illegal private clinic
Anxiety related to psychological conflict and situational depression
George asks Jamal for his professional nursing opinion about the positives and negatives of deciding to travel to another country to sell a kidney. Jamal uses his training in ethical considerations to help George.
First, they consider the ethical principle of utilitarianism, which states that actions are good if they produce happiness and bad if they cause unhappiness. George notes that selling a kidney would bring him happiness because the $75,000 he earns will improve his financial security. Jamal questions his thinking by asking how happy George would be if the surgery was performed incorrectly and caused renal failure, or if George developed a life-threatening infection after surgery.
Second, they consider the principle of Kantianism, which is centered on making choices based on a sense of duty and morality. Jamal points out that this surgery is technically unlicensed and unregulated, and therefore morally wrong. George argues that it is his kidney and his body, and no one should have the power to tell him what he can do with it, illustrating the principle of autonomy.
The discussion moves on to the ethical concepts of beneficence and nonmaleficence. Jamal, in his role as nurse, advocates for George’s best interests. He teaches George about all of the potential complications of a nephrectomy (removal of a kidney), including hemorrhage, infection, pneumothorax, and azotemia, and points out that George may be making the decision based on his current depression. As noted by Peplau, advocacy is an essential role of the nurse (Merritt & Procter, 2010).
Using the principle of veracity, which is truthfulness, Jamal expresses his concerns about George making this life-changing decision. George argues that he has been taking antidepressant medications and is no longer depressed. He states that selling a kidney is the only way to move forward in his life without being a burden on society. Jamal explains that the fluoxetine may not have reached peak effectiveness or the dose might need to be increased. He believes that George should make the final decision about how to proceed, but only when his depression is resolved and he has all the facts.
During the next 2 weeks, George considers Jamal’s points. He researches the patient outcomes of organ sellers who have used the private Mexican clinic, and learns that 50% of patients suffered postoperative complications and several have died. As the fluoxetine reaches full therapeutic effectiveness, George’s depression lifts and he intensifies his job search. He realizes that he has three options.
First, he can ignore Jamal’s concerns and travel to Mexico for the nephrectomy. Choosing this option meets his desire for autonomy. He will benefit financially but risks his health because of the 50% complication rate. He is also negating Jamal’s efforts of beneficence and nonmaleficence.
Second, he can elect to take no action, which is an action in itself. In this case, George does not travel to Mexico, so he does not risk his health (nonmaleficence). He does not find employment and is left homeless, which does not lead to utilitarianism (the greatest good).
Third, he can decide to find a new solution to his financial and housing problems. He can move in with his parents, who will offer emotional and financial support, and look for job opportunities in his home town.
George continues to believe in ethical autonomy, that is, individuals should have the right to sell their own body organs if they choose. He notes that in many states, people can sell their blood. George believes that selling one of duplicate organs is an extension of that right.
However, he also believes in respecting moral and ethical laws (Kantianism). He is concerned that the clinic is unlicensed and unregulated. George also questions the outcome of a procedure in which half the participants experience complications. He realizes that the surgery may not be in his best interest and decides to contact his legislators to support a bill that will make the sale of one’s own body organs legal within the United States.
Meanwhile, George selects option 3. He moves in with his parents, which temporarily relieves his housing and financial dilemmas and enables him to maintain a healthy professional relationship with Jamal. After an extensive job search, George finds an entry-level business position, and is able to build his savings with a long-term plan of buying a home. He is weaned off the antidepressant medication and his health remains excellent, with both kidneys intact.